Prevalence of Gender-Affirming Surgical Procedures Among Minors and Adults in the US

This cross-sectional study uses a national dataset to examine the prevalence of gender-affirming surgical procedures among minors and adults in the US.


Data:
This study used 2019 data from Inovalon Insight's Real-World Data (RWD), which captures administrative insurance claims of people in Medicaid managed care organizations, Medicare Advantage, and commercial insurance across all 50 states.Patients' race and ethnicity was missing for the majority of people and was not included in this study.The study sample was limited to people with active insurance enrollment in 2019 who had at least one insurancecovered medical claim within the year.

Identifying gender-affirming procedures among Transgender and Gender Diverse (TGD) people
2][3][4] (eTable1).]5,6 (eTable2) Of note, clinical guidelines and insurance companies generally require that TGD people have a TGD-related diagnosis prior to initiating gender-affirming procedures. 7Thus, we identified gender-affirming procedures on TGD people as a gender-affirming surgery on a patient who had TGD-related diagnosis within 6 months of the surgery.We then retained only surgeries where patients had no other medical indications which could clinically justify the type of procedure done within 6 months of the surgery (exclusionary diagnoses for each procedure-type can found below in eTable 3).eTable 4 contains a list of diagnoses which, if present within 6 months of a patient's surgery, resulted in manual review of patient history by clinical experts to determine if the surgery could definitively be deemed gender-affirming.Lastly, we excluded all surgeries done on intersex individuals to align with proposed legislative regulations which explicitly do not restrict procedures on intersex minors. 8(eTable 5) It should be noted that these legislative allowances for surgeries on intersex minors stands contrary to growing international human rights agreements which prohibit non-consensual medical procedures on young intersex people. 9fter these steps, we calculate the annual rate at which people underwent gender-affirming surgeries with a TGD-related diagnosis per 100,000 overall people within specific age categories.Additionally, we report the proportion of gender-affirming surgeries among TGD people that were chest-related procedures.
We also determined the number of breast reductions which occurred annually across TGD people and cisgender males.We first identified all breast reduction surgeries (CPT codes 19318,  19300).If the patient had a TGD-related diagnosis within 6 months of the surgery, they were considered TGD; those without a TGD-related diagnosis within 6 months of the surgery and a male sex marker were considered cisgender males.Again, we excluded intersex individuals, as well as any patients with other medical indications for a chest-related procedure within 6 months of the surgery (see "Chest" procedure-type exclusionary diagnoses in eTable 3).We then determined the proportion of breast reductions performed on cisgender males and TGD people.2][3][4] Only procedure codes that alone can be considered gender-affirming were included in the list above and used to identify receipt gender-affirming surgery.For example, procedure codes for skin grafts or injection of filling material were not included in the list above.

F64.2 Gender identity disorder of childhood F64.8
Other gender identity disorders F64.9 Gender identity disorder, unspecified F65.1 Transvestic fetishism Z87.890 Personal history of sex reassignment Note: TGD-related diagnoses were defined from prior work and insurance coverage lists.

Note:
The diagnosis codes used to identify intersex people draw from previous work. 10,11
Exclusionary diagnoses for ruling out gender-affirming surgery, by procedure type Diagnoses indicating manually review of patient history is necessary to determine whether a surgery was definitively gender-affirming © 2024 Dai D, et al.JAMA Network Open.eTable 3: © 2024 Dai D, et al.JAMA Network Open.© 2024 Dai D, et al.JAMA Network Open.© 2024 Dai D, et al.JAMA Network Open.© 2024 Dai D, et al.JAMA Network Open.